Provider Demographics
NPI:1255390118
Name:SHANABROOK, KEVIN R (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:R
Last Name:SHANABROOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 AMHERST ST
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-2808
Mailing Address - Country:US
Mailing Address - Phone:540-536-8000
Mailing Address - Fax:540-536-7681
Practice Address - Street 1:1840 AMHERST ST
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22601-2808
Practice Address - Country:US
Practice Address - Phone:540-536-8000
Practice Address - Fax:540-536-7681
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101045907207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0046813000Medicaid
VA6050042Medicaid
VA6050042Medicaid